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Amid a serious pertussis epidemic in the state of California, an investigative think tank called the Watchdog Institute recently reported that vaccine refusals are on the rise. Their research of CA schools showed that waivers signed by parents who choose to exempt their children from immunizations for kindergarten enrollment have nearly quadrupled since 1990. Specifically, personal-belief exemptions granted to entering kindergartners in the state of CA reached a record high of 10,280 in public and private schools last fall, up from 2,719 in 1990.

You have probably heard the term ‘herd immunity’ before. If not, you can probably venture to guess what it references. Simply put, if enough people are immune to a specific disease, it significantly reduces the ability of that disease to spread. (I’ve covered this in an earlier post entitled, “Measles & Immunity: It’s All In the Numbers”.) In order for immunizations to remain most effective, we rely on a large percentage of the population to be protected from the disease. While there is a different “tipping point” for various diseases,generally speaking health officials prefer that immunization rates remain upwards of 90% in order to provide the best protection.

Obviously, there are some children that have legitimate medical reasons that require medical exemptions. However, the public health concern lies more in the growing trend of parents who are utilizing personal exemptions and shifting the numbers of immunized students in a way that may ultimately threaten herd immunity. While this is common knowledge amongst vaccine advocate groups, this may be surprising to many parents who believe all students must be immunized before coming to school. Most parents don’t realize the popularity of personal exemptions in some areas. They may also wrongfully assume that unvaccinated children are concentrated in lower income areas, resulting from limited access to vaccines due to lack of education or finances. While there are still economic barriers to vaccination, what the Watchdog studies indicate is that personal exemptions are more likely to be utilized by the more affluent parents, and schools with the highest exemption rates tend to be private schools, public charter schools, and traditional public schools in affluent areas.

As the recent San Diego Union-Tribune article reports, states with easy exemption procedures were associated with a 90 percent higher incidence of pertussis compared to states with difficult procedures and for each one percent increase in exemptions at a school, the risk of having a pertussis outbreak went up by 12 percent. These statistics, from studies conducted in 2000 and 2006, come from the Journal of the American Medical Association. Of significant concern, is the study of measles outbreaks, which illustrated how 11 percent of the vaccinated children in the outbreak were infected through contact with somebody who was exempt.

Now, let’s consider the significance of these studies for a moment. High exemption rates link to higher incidence of disease and transmission to vaccinated children. Concerning? Yes. However, a parent who chooses not to vaccinate their children will argue that if immunizations are effective, than we shouldn’t be worried about their unvaccinated children in the classroom. Shouldn’t the vaccines we give our children protect them from anything their non-vaccinated children are carrying? And if the vaccines don’t protect them, than aren’t we admitting that vaccines are not effective?

While that may sound like a valid argument, what science proves is that nothing is 100% effective – including vaccines. Within every scientific model there are limits to be considered. I particulary like the way this was explained in a recent article on the Respectful Insolence blog.

“Of course, anti-vaccine parents both demonize and have unrealistic ideas about what vaccines can do, which is part of the problem. They demonize vaccines as the cause of autism, autoimmune disease, and asthma, along with all sorts of other health problems, even though there is no scientifically credible evidence linking vaccines to autism or any of the other conditions attributed to vaccines. Yet, at the same time, they justify their refusal with the implicit belief that vaccines are 100% effective. I refer to this as an “implicit” belief because a frequent argument made by anti-vaccine parents when it is pointed out to them that they are endangering other children is that those other children are vaccinated; so how could their precious baby ever be a threat to other children? The reason, of course, is that no vaccine is 100% effective. Some, like the MMR vaccine, are “only” around 90% effective. Now, in medicine, 90% effectiveness is in general excellent, about as high as one can expect from any intervention. It’s not 100%, though. Worse, pockets of unvaccinated children provide a repository for vaccine-preventable disease that can infect other unvaccinated children, as well as vaccinated children who, for whatever reason, did not develop effective immunity due to their vaccination.”

Add to the fact that protection often wanes over time, (a time window that may vary from person to person), and you can understand why the CDC immunization recommendations include booster shots for both children and adults. This has proven to be another step public health advocates are currently taking to reduce the spread of diseases like pertussis, especially in states like CA. However, legislation is just taking hold and some states now require booster shots for school admittance as well.

Personally, I do my part to ensure my children are up to date on their recommended vaccines, not only for their own protection, but because I believe that the vaccine requirements are part of the school’s responsibility to ensure the best means of public health possible. Similarly, I expect the school to enforce other precautionary measures that will keep my children safe, such as practicing bus safety and conducting fire drills. These days they even conduct “bad person” drills that are intended to prepare kids in the event that a dangerous person enters school property and threatens the safety of the students.

While I believe these risks are minimal, it doesn’t mean I don’t support the school preparing for these situations. I am not foolish enough to believe that these things couldn’t happen in my child’s school or my community. No amount of money or security can eliminate the risk, but we can prepare ourselves for these situations with proper precautionary action.

Likewise, I see immunizations in the same way. Just because my children are healthy, exercise, eat well and wash their hands doesn’t mean they will never fall victim to disease; especially highly contagious and dangerous diseases like measles or pertussis. So why is it that immunizations, which are a safe and effective precautionary step in the prevention of disease, are being dismissed by educated, affluent parents?

Certainly, this is a growing concern, but the million dollar question remains. What can we do to change these parental attitudes and protect these children, as well as the community at large, from vaccine preventable disease? There is a school of thought (no pun intended) that some schools are no longer enforcing vaccinations, but enabling the questionable use of vaccine exemptions. Would you believe that Whatchdog report lists the private Waldorf School in San Diego county with as many as 51% of their students unimmunized due to personal belief exemptions? It isn’t surprising that the administration supports this anti-vaccine sentiment. Shouldn’t our school systems be trying to educate parents about the risks of wide-spread disease and the public health responsibility we have to our community at large?

Perhaps more concerned parents should demand to know how many of their children’s classmates are coming to school unvaccinated. As Dr. Mark Sawyer, pediatric infectious disease specialist at Rady Children’s Hospital in San Diego noted, “Un-immunized people in general contribute to any disease rates. As the rates of un-immunized kids go up, we are inevitably going to see more and more outbreaks of diseases.” It is clear that a failure to vaccinate children attending school endangers us all.

How many of your child’s classmates do you believe to be immunized? How would you feel if they weren’t? We would like to hear your thoughts so please share your experiences by providing a comment below.

Recently, there has been some interesting discussion in the media regarding the Hepatitis B vaccine. The CDC suggests that this vaccine be administered to infants soon after birth and before hospital discharge. Parents, who are often uninformed regarding the risks of contracting this disease or the chronic long-term effects of liver failure, cirrhosis, and liver cancer that come from being infected, may question why their infant needs to receive a vaccination at such a young age. As a parent to five children myself, I too wondered why it was so important to begin vaccinating my child before they had even left the hospital.

During the recent airing of the PBS Frontline piece entitled, “The Vaccine War,” one parent defended her anti-vaccine views by questioning why her newborn child would need a vaccine against a sexually transmitted disease. This comment, as well as many other misconceptions I have read and heard recently, explains the need for public education regarding the risks of the hepatitis B virus (HBV). Once parents understand the unique risks that this virus poses to their infant child, I hope they will vaccinate them at birth to protect their children from a disease that can have chronic effects later in life.

According to information provided by the Immunization Action Coalition and the CDC, an estimated 1.25 million people are chronically infected with the hepatitis B virus in the United States alone, resulting in an estimated2,000-4,000 deaths each year. Surprisingly, 30%-40% of these chronic infections were acquired during childhood. This fact alone presents a compelling case for vaccinating infants – before they become infected.

Parents need to understand that the hepatitis B virus can be spread by infectious blood and body fluids, and not solely through sexual contact. As a parent myself, I can recall countless times that I have tended to children, both my own and others, who have suffered scrapes, cuts, nose bleeds and even bites from frustrated playmates. These are realistic opportunities for exposure since the CDC has stated that the virus remains viable and infectious in the environment for at least 7 days and can remain present in inanimate objects absent of visible blood. Since only 7 out of 10 infected adults show any signs or symptoms, and infected children under age 5 rarely show any symptoms at all, it is obvious how the infected population can easily, and unknowingly, be transmitting the disease to others.

One of the issues that Deborah Wexler, from the Immunization Action Coalition, addresses is that many of those who become infected with the hepatitis B virus contract the disease from their unknowingly infected mother at birth. Dr. Wexler explains, “There are so many parents and healthcare professionals who think this vaccine is wrongly given at birth for an STD that might be acquired later in life. But the most important reason for it is to prevent HBV infection early in life with the possible life-long complications of chronic disease in the form of liver failure and liver cancer that affect so many who are infected at birth. I wish this message were more broadly disseminated, but it is a difficult message to discuss due to its complexity, the need to explain how medical errors might occur and why testing isn’t infallible, or how exposures could occur in an infant.”

While OBGYNs suggest the mother be tested prior to delivery, there are many instances when this does not occur, or when it is possible that the mother contracts the disease in the period after testing, but before birth. Properly identifying infected mothers is complicated since there can be errors in test ordering, result interpretation or even test inaccuracy. Therefore, administering the first dose of the hepatitis B vaccine soon after birth minimizes the risk for infection from the mother or from other infected persons who may be living in the household. Additionally, the hepatitis B vaccine can actually help prevent infection in infants who are born from mothers with the virus in their blood. This serves as another important fact to support vaccinating your child according to the recommended schedule.

Studies also indicate that the long-term chronic health issues related to this virus, such as liver failure, cirrhosis, and liver cancer, are directly related to when a person is first infected. For example, 90% of infants who are infected will ultimately develop chronic symptoms later in life, however, when the illness is contracted at an older age, the chronic effects are less prominent. Only 30% of children age 1-5 who contract hepatitis B will go on to develop these chronic issues. Once again, these figures demonstrate the benefit of starting infants on the multi-dose vaccination series as soon as possible after birth in order to provide the greatest preventative effect on the population.

Perhaps you have other concerns or information to share regarding the hepatitis B virus. Feel free to comment here or respond with a question so that you can be part of the conversation.

By Dr. Ari Brown, Practicing Pediatrician and Author of Baby411, Toddler411 and the soon to be release Expecting 411

My brother passed away recently. He was only 57 years old.

Like so many people whose lives end prematurely, he died from cancer—specifically, liver cancer (hepatocellular carcinoma)—which is often caused by a previous Hepatitis B infection. The cancer shows up several years later. My brother had a Hepatitis B infection about 35 years ago. Because he had other chronic health problems, no one will ever know if this infection is what led to his cancer and subsequent death, but I will always wonder and it will haunt me the rest of my life.

As a pediatrician, I talk about Hepatitis B disease and vaccine with the parents of every newborn patient. One of the really cool advances in modern medicine is the development of cancer-preventing vaccines. Hepatitis B vaccine has the honor of being the first cancer vaccine ever created. It was developed in the 1980’s and it became part of the routine childhood immunization schedule in 1991. Babies usually get their first of three doses before they even leave the hospital.

Over the years, I’ve encountered parents who have reservations about giving their child this vaccine. I hear, “My baby isn’t at risk,” or “It’s spread by having sex, so why give it to my baby now?” But like every other vaccine, it is all about prevention. It doesn’t matter when you THINK your child might encounter a potentially deadly infection. The truth is, you never know and cannot control when that might happen. About 30% of people who get Hepatitis B infections are not considered “high-risk” for getting infected.

After losing a loved one to liver cancer, I can’t imagine why a parent would opt to leave their child at risk.

An ounce of prevention is worth a pound of cure. I think my brother would have agreed.

Dr. Ari Brown holds a bachelor’s degree in child development from the University of Texas at Austin and a medical degree from Baylor College of Medicine. She completed her pediatric residency and a fellowship in developmental/behavioral pediatrics at Harvard Medical School/Children’s Hospital Boston.

Meningitis Angels was founded in memory of Ryan Wayne Milley, only child of Bob and Frankie Milley. Ryan died at the age of 18 from meningococcal meningitis. Frankie now leads a large network of “angels” who have been affected by meningitis and speak out to raise awareness about this disease.

Just a little over a month ago I went to Oklahoma to help out the little town of Oologah during a serious outbreak of meningococcal meningitis with Angels Amanda and Abby at my side. It was devastating to see what this horrific vaccine-preventable disease could do in just a few short hours. It brought back those horrible memories of watching my only child, my precious Ryan, lay dying on an ER table. The days were filled with hospital visits, funeral homes, heartbroken families, legislators, health department folks, vaccine clinics and a blizzard on the first day of spring.

This weekend I will once again return to this little town. Only this time, to celebrate World Meningitis Day at the same little school where life was taken just a few weeks ago. Angels, Leslie, Karisa, Harley and her mom Donna, and Angel family the Menards, will be there. I pray with our candlelight visual, special music, flower seeds and a balloon launch with messages of love that we can bring just a glimmer of peace, hope and joy to this little town.

Most of all I hope that there is increased awareness about the vaccines which prevent this disease so that no more lives will be sacrificed from this deadly vaccine preventable disease.

A recent NPR article I read chronicled a measles resurgence tied to people who intentionally choose to go unvaccinated. In Vancouver, foreign travelers to the Olympics apparently brought with them more than luggage. In fact, they were carrying two different strains of the measles from Asia.

It’s not surprising really. The Olympics is the pinnacle of international sports and people swarmed to Vancouver to be a part of it. However, with the global traveler comes the threat of contagious diseases and, so far, the disease has spread to 16 people in Vancouver, with half of them residing in one large unvaccinated household.

Similarly in 2008, a seven year old boy, who was an intentionally unvaccinated US resident, returned from a visit to Switzerland and unknowingly exposed 839 people to the measles. Of these 839, 73 were unvaccinated children (25 of these children from households that chose not to vaccinate) and 48 were children younger than 12 months old and yet to receive the measles vaccine. To limit the spread of the virus any further, parents of those 73 unvaccinated children were asked to isolate their kids by keeping them home for three weeks! Trust me: that’s no walk in the park for any parent.

Fortunately, in that case, the vigorous response from public health agencies helped to track and contain the outbreak. But what do we expect to find with this outbreak in Vancouver? According to NPR, just a generation ago, up to 4 million U.S. children got measles every year, hundreds died, and thousands were left with permanent brain damage. It became a national health crisis and a vaccine was eventually developed that effectively protected people from contracting measles. Nowadays, many people do not consider measles a threat. After all, you hardly ever hear about it. And many people have never seen it. In fact, I wonder how effective today’s doctors would be in diagnosing it since it is not all that prevalent. Perhaps that justifies the choice some people make to forego the available vaccine.

So, I had to ask myself the question: If the numbers of unvaccinated people influence the spread of diseases, but are not large, just how many people need to refuse vaccines in order for these diseases to resurrect themselves in greater numbers and with more severe outcomes? In other words, what is the percentage of unvaccinated people that will tip the scales of social health away from overwhelming protection from a disease due to high rates of immunization—what health officials call “herd immunity”?

Shockingly, experts say measles is so contagious that more than 95 percent of a population needs to be immunized in order to prevent mass infection. If as little as five percent of people go unvaccinated, the herd immunity becomes threatened, resulting in a higher number of vulnerable children. It’s surprising that such a small percentage of unvaccinated population can contribute such great risk. However, health officials say there are growing pockets of “vaccine refusers” across the country, giving viruses like the measles the opportunity to impact public health at much greater levels.

Now it’s important to note that in some communities in this country there are as many as 10 percent of the childhood population that goes unvaccinated so this is a definite concern in the U.S. Consider another NPR article, dated April 5, regarding a recent measles epidemic in Zimbabwe where the official count is over 2,000 cases and about 200 deaths. The Zimbabwean Health Minister highlights the importance of herd immunity saying, “estimated coverage for measles is well below 70 percent, so there’s no herd immunity.” The article goes on to say that the epidemic began in two sects whose leaders oppose vaccination. As more and more Americans refuse vaccinations, is this what we have to look forward to?

Currently, herd immunity, as unflattering as it may sound, might be one of the primary factors protecting the very people who choose not to immunize. While I would not interfere with the fact that people should have a choice whether to vaccinate or not, I am concerned about the numbers. Fortunately there are still enough people receiving vaccinations to protect the community at large. Because others are vaccinated, it greatly reduces the risk of the unvaccinated. However, as in the cases cited above, unvaccinated individuals are typically the first to fall victim to a case of preventable disease.

What are your thoughts on herd immunity and its effectiveness in protecting our population from major, preventable epidemics?

Well, to sum it up, I am an educated woman with a diverse background in communications and public service. I’m married to a wonderful man whom I adore, but rarely see due to his dedicated 25 years of military service and frequent deployments. Fortunately, I have mastered the art of relocating, and recently completed my sixth move in 15 years (which is actually not bad as far as military families go). Throw in the fact that I have five children between the ages of four and 13 and you can begin to imagine how my life can be complex, to say the least.

Friends and family would agree that I am an overachiever. While I hate to admit it, I’m also a perfectionist who often struggles with the decisions that I make as a mother. I would say that while I can make decisions, I struggle with the possibility that I might make the wrong decision, so I commonly belabor every choice. I try to be fair in how I formulate my opinions as a mother, wife and woman in my day-to-day life. I believe that there are two sides (or more!) to every story (which is often exemplified in how I deal with arguments between my children). Most importantly, I believe we all have the right to our own opinions and that a healthy dialogue about our views is the key to greater understanding of any topic. Which brings me to Shot of Prevention.

Like any mom, the birth of my first child brought about great joy and new choices that I would have to make. Natural labor or epidural? Pacifier or no pacifier? Breastfeed or bottle feed? Vaccinate or not vaccinate? After much investigation and discussion, I realized that each choice had its own set of pros and cons. Ultimately, the decisions that my husband and I made would forever impact our own lives as well as those of our children.

Parenting choices only continue throughout your life and over the course of the past year, I have come to realize that vaccination is also a lifelong process. Recently, my oldest child was offered the Gardasil vaccine, my youngest child received a list of immunization requirements for kindergarten and another child contracted H1N1. I suddenly recognized that vaccines are not just something to concern ourselves with while our children are young. This is a science that continues to evolve and with the recent attention on current vaccine news, I am now committed to keeping myself engaged in the dialogue.

Join me on my journey

Unfortunately, what I have found is that the vaccine dialogue can be very clinical, and subsequently confusing, to those of us who are not well versed in “public health speak.” The challenge lies in seeking out reputable sources of information to assist us in educating ourselves about the benefits, concerns and effective uses of vaccines to protect us from preventable diseases. As parents, we decipher an enormous amount of information from doctors, scientists and public health advocates, while also being influenced by the questions and concerns of our family, friends and neighbors. I have been familiar with Every Child By Two (ECBT) for some time now, and have consistently found this organization to be a credible source for fact-based information on vaccine safety. For this reason, I’m honored to partner with ECBT and the Vaccinate Your Baby campaign as a contributor on this blog. As a writer and a parent, I will be discussing these issues closely with Shot of Prevention co-editor, Amy Pisani and other ECBT staff on a regular basis.

I invite you to join me on my journey, as I attempt to make sense of the mixed messages I often hear regarding vaccines. There have been several recent events that have prompted both confusion and curiosity for me, and I hope to reveal them to you on Shot of Prevention .Through the exposure of this blog and other social media venues, I will hopefully encourage an open dialogue where I can not only address various questions of mine, but shed light on a multitude of questions that you may have. Therefore, please always feel free to leave a comment on my entries or submit questions for future discussion. I promise to read each and every one of them.

A new study that was released by researchers from the University of Michigan and published in the journal Pediatrics this week revealed some bittersweet news about parents’ attitudes toward vaccinating their children. While the survey of 1,552 parents found that one in four U.S. parents believes some vaccines cause autism in healthy children, the study also found that most parents continue to follow the advice of their children’s doctors, with nine out of ten saying that they parents believe that vaccination is a good way to prevent diseases for their children.

The information from this survey tells me that public education campaigns conducted by organizations such as Every Child By Two and many others (click here for a list) fill a critical role in conveying scientific information to the public. It’s only natural that parents will have questions about their children’s health, but it’s up to the public health community to answer them in a clear and comprehensive way. As lead author of the study Dr. Gary Freed says, most of parents’ fears are unfounded, so it’s essential that “physicians … take parental concerns seriously. They need to be aware of and familiar with the data on the safety of vaccines, because parents deserve to have concrete info on vaccine safety.”

Doctor-patient communication is critical, and the American Academy of Pediatrics, Centers for Disease Control and Prevention (CDC), and American Academy of Family Physicians (AAFP) partnered to develop some great resources for providers to communicate with parents about vaccine concerns. Click here to check it out.

In order to better prepare parents prior to their child’s vaccines, I’d like everyone to share with their friends and family some credible resources to which parents can turn to have some of their tough questions answered. For example, Every Child By Two posed some frequently asked questions to several experts in the fields of immunization and autism and recorded the expert answers here.

Another item that concerned me was that parents believe that newer vaccines are untested, and less safe than ones that have been around longer. I want to reiterate that all vaccines go through the same, very stringent and lengthy, regulatory review process. Because vaccines are given to healthy individuals, they undergo a more rigorous approval process than drugs which are given to cure sick people. Vaccines are also tested in combination with one another so that they are proven to be safe in the context of the CDC schedule as well. Licensing of vaccines typically takes 15 years and an average of $800 million of manufacturers’ money. For more info on this process, click here, or visit the FDA web site.

Finally, the study also pointed out that although Hispanic families have the lowest rate of vaccine refusal as compared to white or black individuals, they were more likely to believe that some vaccines cause autism. The researchers suggested that “addressing this concern explicitly before it has an impact on immunization rates should be strongly considered by both public health officials and private providers in these communities.”

I hope that you will share this information with any concerned parents out there who may not have had all of their questions answered!